A Hospital Trust has admitted a communication error led to the blood tests of a patient who’d suffered serious burns to his leg not being assessed by doctors – missing developing sepsis which caused his death.
The 72-year-old patient was admitted to Rotherham General Hospital after suffering burns to his left leg when collapsing in a local health club steam room.
Despite the seriousness of the burn – which stretched from mid-thigh to his lower calf – he was not sent for review at a specialist burns unit for 13 days, by which time he suffered a cardiac arrest on arrival and died.
During his time in the Rotherham hospital, requested blood tests and swabs, which would have alerted doctors to the worsening infection and onset of sepsis, were not checked.
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Serious Incident Review
A Serious Incident Review into his death identified ‘a lack of escalation and management of deteriorating patient’, and a ‘breakdown’ in communications which led to blood tests not being checked resulting in sepsis negligence.
Had they been checked with the swab results, doctors admitted intravenous antibiotics would have been prescribed rather than oral antibiotics, observations would have been more frequent, and the patient’s death would have been prevented.
Now, following a successful legal case against Rotherham NHS Foundation Trust through Hudgell Solicitors – in which a substantial damages settlement has been agreed – the man’s furious family say a ‘circle of failures’ robbed them of a much-loved father and husband.
The errors also denied the man the chance to enjoy becoming a grandfather for the first time, with his daughter finding out she was pregnant just five days after he passed away.
She says the failures in communication and a lack of urgency over treating his condition were ‘unforgivable’, and is urging other families to question the care their loved ones receive if they feel not enough is being done. His daughter said:
My father’s basic care needs were not looked after. He was completely let down in every aspect of his care. Despite us raising our concerns as a family, we were ignored and dismissed.
Our family has a medical background and we were telling them things weren’t right and that there was something more serious going on but they didn’t listen. My mum worked in medical care within the hospital and she saw the danger signs. She was worried he may lose his leg.
My dad had taken pictures of his leg without the dressing and it looked badly infected and to be getting worse. We did challenge and question things but we wish now that we had been more forceful. Everything we said was just brushed off.
They simply didn’t seem to see the danger developing and were suggesting at one stage that it was his mental health deteriorating, but anybody who knew my dad would have known that was not right.
He was of sound mind and sharp, and he wouldn’t have deteriorated so quickly in the mind. The signs of something else going wrong were there.
My advice to others from our experience is to question the care, and question each and every doctor or nurse you see come into contact with your loved one. You assume they are fully briefed and knowledgeable but they are not always.
My father died because staff were simply not passing on details which made the difference between life and death. Doctors making decisions didn’t have the right information at hand. There were many, many people involved in his care at the hospital yet not one person took responsibility.
There was no consistency, crucial details were not being properly and accurately passed on from shift to shift and that led to them failing to check his blood results. It is shocking and we as a family still feel so much anger and upset.
I work in a role at a business where if I made such a mistake where important details were not passed on to colleagues I’d be sacked, and there are no lives depending on my job.
Legal case highlighted ‘failure to ensure hospital staff were adequately trained and aware of sepsis’
It took seven days in the hospital before the patient was referred to the specialist burns unit at Sheffield Northern General Hospital, but even then he was not transferred due to a lack of vehicles available with oxygen.
The family say they offered to drive him to the specialist unit themselves, something doctors would not allow them to do.
It transpired that the doctor who’d ordered he be taken to the specialist burns unit was not made aware it had not happened, meaning he wasn’t reviewed again and provided with appropriate wound dressing and treatment.
The man should also have had an urgent medical review in the early hours of the morning prior to his death and his transfer to the burns unit, which was also missed.
As part of a legal case against the Trust, Hudgell Solicitors claimed the lack of appropriate action led to the wound becoming infected, resulting in sepsis which caused cardiac arrest, hyperkalemia and ultimately his death.
In allegations of breach of duty – which the Trust did not contest – it was said that there had been a ‘failure to ensure staff were adequately trained and aware of the symptoms and indicators of sepsis.’
Failures to re-refer him to the emergency department, change dressings when required, check blood tests, provide senior doctors with full information and increase the number of observations were also highlighted.
The Trust admitted these errors had caused the patient’s death.
Firm highlighting the ‘need for speed’ in sepsis diagnosis
Hudgell Solicitors have been campaigning to raise awareness of the ‘need for speed’ in sepsis diagnosis to save lives.
Statistics show that patients diagnosed with sepsis and treated appropriately within the first hour have an 80% chance of surviving, but after six hours without treatment, it will reduce to just 30 per cent.
Speaking about this case, medical negligence specialist Gemma Bontoft, said:
The sad facts of this tragic case are that a man has lost his life because hospital staff were not alert to the dangers of sepsis and did not take simple steps, which were policy within the Trust, and would have prevented the sepsis from developing to the level it did, ultimately preventing his death.
Blood tests were not checked following a request from a consultant, and these blood results would have shown inflammatory markers to be elevated, which in addition to the lack of improvement in his wound, should have resulted in the patient being prescribed intravenous antibiotics.
He was in hospital for almost two weeks during which time he was becoming gravely ill due to the infection and worsening sepsis which medical staff were completely oblivious to, and the staff that had raised concerns were not advised of.
It was an appalling standard of care. Sadly, we see far too many cases where the most simple tasks, and the most basic mistakes, cost lives. It is heartbreaking for families.
We are pleased that we have been able to hold the Trust to account for these errors, but nothing can bring back this much-loved family member.
Settlement finally offers family chance to grieve
The man’s daughter says she hopes the conclusion of the legal case, and the admissions of fault from the Trust, will finally give her family the chance to grieve.
She says it has also highlighted the need for people to seek specialist legal advice, as the final damages settlement agreed was more than 10 times higher than the first amount offered by the Trust, once the impact of financial loss on both herself and her mother had been taken into account. His daughter said:
It has been so tough for us all over the past three years.
Initially, when we questioned his care we were given the impression nothing had gone wrong or could have been done. It was only when the Coroner delayed the funeral and said he was not happy and wanted to investigate the circumstances that we began to realise our concerns had been valid.
I think the completion of the legal case is a line in the sand. We have held the Trust to account and they have had to accept their fault. If you don’t take action it gets brushed under the carpet and that is not right or acceptable. Legal action is the only way you can go.
Also, whilst this was never about financial compensation, without the right legal representation we would have received much less than we did. It is meant to be compensation for taking someone’s life, but I feel the NHS are not respecting families. They are looking to get out of it with the smallest financial hit.
For my mother it has been very tough. She lost the person she was with every day of her life for three decades. She moved house because it was so difficult without my dad around, and she left her job at the hospital as it was repeatedly a reminder for her. People at the hospital would ask about it, and she’d be seeing the people whose mistakes ultimately cost my dad his life.
We remain angry and upset at how this could have been allowed to happen. My father was somebody who demanded the best care and the best service, so he would have been appalled.
The time around his death was such an emotionally difficult time. I found out just five days after he died that I was pregnant with his first grandchild. He would have doted on her.
I don’t think I’ve fully grieved as I have been caught up in investigations, inquests and legal cases since. My mind has been overtaken by fighting for answers and justice. Now I can hopefully just remember my dad as he was.
I’ll remember how he had a nice life and was enjoying his retirement years.
He loved his retirement and would go to the gym every day and spend a few hours there having a swim, enjoying the steam room and sauna. He was health conscious, and as he had a chest condition he did everything he could to make it better.
That’s what makes it all the more sad. The people who were supposed to care for him when he needed it let him down and took him from us. We can’t forgive them.
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